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Evergreen Care Center

5265 East Huntington Avenue, Fresno, CA 93727 · For profit - Limited Liability company · 49 certified beds · (559) 251-8244 Medicare & Medicaid certified

Call the home — (559) 251-8244 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 20242 actual-harm citations
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5043 E Kings Canyon Rd · (559) 369-4421 · Call to confirm hours
Pharmacy
5180 E Kings Canyon Rd · (559) 255-9009 · Call to confirm hours
Grocery
1004 S Peach Ave · (559) 251-1002 · Call to confirm hours
Park
Trolley Creek Park, 5110 E Huntington Ave · (559) 456-3292 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.1%10.2%15.4%typical
Long-stay residents who lose too much weight2.9%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms8.7%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.4%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened25.6%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication33.8%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.6%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control30.7%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table13.0%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine93.7%93.2%79.4%better
Short-stay residents rehospitalized after admission23.9%23.0%22.6%typical
Short-stay residents with an outpatient ER visit20.0%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.742.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.291.571.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.2%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
42.3%U.S. median 56.6%
Met the expected recovery
0.56U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 42.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 26 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.2%CMS range 38.4–75.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.9–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge42.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge26.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified84.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 3.5–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.361.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.62
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.79
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
0.48
RN hoursweekends
51.5%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 49 beds and averages 46.3 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.79 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.89 hrs/resident/day on weekends vs 4.33 on weekdays — 10% thinner on weekends. RN hours go from 0.68 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2024-05-17)
10
at the previous standard inspection (2019-05-23)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

35 citations, most serious first. The 12 most serious are shown; the remaining 23 are one tap away and print in full.

  • Actual harm · G2025-03-11 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on [DATE] and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. This failure resulted in Resident 1 being exposed to triggers that caused her re-traumatization from past experiences with feelings of isolation, depression, lack of sleep and fear. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2019-05-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure each resident was free from sexual abuse for one of three sampled residents (Resident 15) when on two separate occasions (3/25/19 and 4/3/19) Resident 38 without permission grabbed Resident 15's breasts in the hallway of the facility. For Resident 15, the facility failed to protect her from sexual abuse from Resident 38 on 4/3/19, ten days after a previous incident of sexual abuse occurred on 3/25/19 with Resident 38. This failure had the potential to impact the physical and mental well-being of Resident 15 by increasing her anxiety and depression from potential feelings of disrespect and violation of her personal body space. Findings: During an observation in the dining room, on 4/5/19, at 12:39 p.m., Resident 15 was sitting in a reclining wheelchair and being assisted by a Certified Nursing Assistant (CNA) with her lunch meal. The CNA was speaking in Spanish to Resident 15. Resident 15 did not engage in conversation with the CNA. During an observation in Resident 38's room, on 4/5/19, at 12:46 p.m.,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an incident of bodily injury that required hospitalization for one of three sampled residents (Resident 1) when Resident 1 had an alleged fall on 5/13/26 and was sent to the hospital due to a head injury. This failure resulted in an inaccurate investigation and reporting to state agencies of events leading up to and resulting from Resident 1's fall with injury.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for blindness to the left eye, myocardial infarction(blood supply to the heart is blocked), heart failure, Peripheral Vascular disease (poor blood circulation in your legs and arms), difficulty in walking, need for assistance with personal care,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a safe and orderly discharge from the facility for one of two sampled residents (Resident 1) when the facility discharged Resident 1 without needed medical equipment that included oxygen concentrator, wheelchair, and shower chair. This failure placed Resident 1 at risk for an unsafe discharge due to the inability to use medical equipment to prevent possible falls, injuries and respiratory distress.Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Diabetes Mellitus (DM- increased sugar in the blood), bacterial infections, End Stage Renal Disease (ESRD- Kidney failure), hypertension (high blood pressure), heart failure, Abnormalities of breathing.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide adequate supervision to ensure safety for one of four sampled residents (Resident 1), when Resident 1 had an order for a one to one staff member supervision due to a physical altercation and the facility did not have staff scheduled on 7/6/25 for the afternoon shift (PM- 2:45 p.m.-11:15 p.m.), 7/6/25 for the night shift (10:45 p.m.-7:00 p.m.) and no staff scheduled for one to one on 7/7/25 afternoon shift.This failure placed Resident 1 at risk for injury from further altercations that could have occurred in the facility.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Anxiety (excessive worry…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-17 · tag F0774 — pattern
    Help the resident with transportation to and from laboratory services outside of the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist residents in making transportation arrangements to and from their provider appointments for three of seven sampled residents (Residents 24, 29 and 40) when: 1. Residents 24 and Resident 40 missed their scheduled appointments due to the transportation arriving late and was not the preferred transportation company requested by Resident 24. This failure resulted in Resident 24 and Resident 40 having to re-schedule their appointments for later dates and caused anger and frustration to Resident 24 and Resident 40's Responsible Party (RP). 2. Resident 29 was not picked up from his appointment by the scheduled transportation company. On 5/21/25 Resident 29 left for a 1:00 p.m. appointment at 12:45 p.m. and did not return to the facility until 5:30 p.m. due to Resident 29 waiting four hours for another transportation company to pick him up. This failure had the potential to place Resident 29 at risk of being exposed to harm and resulted in Resident 29…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-11 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to designate and employ a full time Director of Nursing (DON) for the facility from 12/2024 to 3/2025. This failure had the potential for all residents to result in inadequate residents ' care planning and supervision of the nursing department which placed all residents ' health and safety at risk. Findings: During an interview on 3/11/25 at 4:38 p.m. with the Administrator (ADM) and Assistant Administrator (AADM), the ADM and AADM stated there was no DON assigned to the facility since 12/2024. The ADM and AADM stated there was a DON that was supposed to start working full time in the facility, but due to unforeseen circumstances, the DON did not begin employment with the facility. The ADM and AADM stated the facility nursing consultant had been completing some DON duties 1-2 times per week but was not full time. ADM and AADM stated the facility should have had a DON from 12/2024 to 3/2025. The ADM stated there were Registered Nurses assigned as supervisor for the day, but were not completing any DON duties. During a telephone…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect and promote the rights of residents' privacy for two of nine sampled residents (Resident 1 and Resident 2) when the facility did not provide a private area for Resident 1 and Resident 2 to discuss their personal health information. This failure had the potential to result in health information for Resident 1 and Resident 2, to have been overheard by other unrelated staff and residents in the facility resulting in lack of confidentiality and privacy. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for Trauma informed Care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1), when the facility's admitting nurse and social services director (SSD) identified Resident 1's history of trauma upon admission and did not create a care plan to recognize trauma and triggers that impacted Resident 1's care. This failure resulted in Resident 1 experiencing triggers that caused her to relive past traumas during her care in the facility. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-26 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident rights were exercised for two of four sampled residents (Resident 1 and Resident 2), when Resident 1 and Resident 2 were denied the opportunity to reheat their food brought in by family past 7:00 p.m. This failure resulted in Resident 1 and Resident 2's rights not having access to reheat their food past 7:00 p.m. causing anger by not recognizing Resident 1 and Resident 2's individuality and autonomy. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), Bipolar disorder (mood swings including sadness and anger). During…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from free from abuse for one of three sampled residents (Resident 1), when certified nursing assistant (CNA)1 was observed hitting Resident 1 with a closed fist. This failure resulted in Resident 1 being physically harmed on the right thigh causing unnecessary mental trauma and physical pain to the area. Findings: During a record review of Resident 1 ' s Nurses Note, dated 11/1/24, the nurses note indicated, . CNA 1 and CNA 2 continued to change Resident 1, Resident 1 ' s aggression increased, Resident 1 began kicking, hitting, and scratching CNA 1. Resident 1 made contact multiple times while swinging at CNA 1, including Kicking CNA 1 in the side of the face and scratching her hand. CNA 1 finished changing Resident 1 and left the room. Resident 1 stated to director of nursing (DON) and assistant administrator, that CNA 1 hit her with a closed fist 2 times on her right upper thigh before CNA 1 left the room . During a review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. One of three kitchen personnel, [NAME] (CK) 2 did not use a surface sanitizer with the correct concentration when wiping the food preparation table. 2. One of three kitchen personnel, CK 1 did not take the temperature reading of food items after the items were heated in the microwave before serving it to one of 47 residents. 3. Plates, Plate holders, lids, and cooking pans were not air dried and were stacked and stored wet in the kitchen. These failures had the potential to expose 46 of 47 residents who received food from the kitchen to pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and cause foodborne illness (illness caused by ingestion of contaminated food or beverages) to residents who ate the food. Findings: 1. During a concurrent observation and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 23 citations
  • Potential for harm · Ecited before2024-05-17 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were provided with dignity and respect for two of eight sampled residents (Resident 146 and Resident 243) when: 1. Licensed Vocational Nurse (LVN) 3 checked vital signs (V/S-measurements of blood pressure, pulse rate and temperature) and administered medication to Resident 146 in hallway B and did not provide privacy. 2. LVN 3 checked V/S and administered medication to Resident 243 in Residents' room and did not provide privacy. These failures resulted in Resident 146 and Resident 243 not being treated with respect and dignity while their vital signs were taken and while taking their medications. Findings: 1. During a concurrent observation and interview on 5/15/24 at 8:51 a.m. in B hallway, Resident 146 was sitting up in his wheelchair. LVN 3 checked Resident 146's V/S and prepared Resident 146's medications. LVN 3 administered Resident 146's medications in the hallway with other residents and staff walking by. During a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dialysis (procedure to remove wastes and excess fluids from the body) communication forms were completed for two of four sampled residents (Resident 142 and Resident 25) when Residents 25 and 142 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) on multiple dates. These failures placed Resident 142 and 25 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through blood vessels)access sites. Findings: During a concurrent observation and interview on 5/13/24 at 7:40 a.m. in Resident 142's room, Resident 142 was observed sitting up in bed, eating breakfast. Resident stated she had hip surgery due to a fracture (break in bone) sustained from a fall at home. Resident stated she had been in the facility for a month and working with therapy to get stronger so she can go back home. During a record review of Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of five sampled residents (Resident 142) when Resident 142 was administered heparin (anticoagulant-blood thinner) medication as prophylaxis (prevention) for venous thromboembolism (condition that occurs when a blood clot forms in a vein) and the facility did not initiate a care plan. This failure had the potential for Resident 142 to experience a thromboembolism. Findings: During a concurrent observation, and interview on 5/13/24, at 7:40 a.m. in Resident 142's room, Resident 142 was lying down in his bed. Resident 147 stated she had been in the facility for a month. Resident 147 stated she had a hip surgery due to a fall at home and sustained a hip fracture (broken bone). Resident 147 stated she was working with therapy to walk again and go home. During a review of Resident 142's admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24, AR indicated Resident 142 was admitted in the facility on 4/17/24 with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide quality of care and treatment in accordance with professional standards of practice for one of four sampled residents (Resident 18) when fasting blood sugar levels (FBS- A test to determine how much sugar is in blood after an overnight fast) was not performed per physician's orders. This failure resulted in Resident 18's blood sugar level not being monitored which could lead to hypoglycemia (a condition where there isn't enough sugar in the blood) or hyperglycemia (a condition where there is too much sugar in the blood). Findings: During a concurrent observation and interview on 5/13/24 at 2:59 p.m. with Resident 18 in his room, Resident was sitting upright in bed eating. Resident 18's both legs were amputated (cut off). Resident 18 stated, his legs were amputated two years ago due to diabetes mellitus (DM-a condition in which the sugar is high in the blood). Resident 18 stated his blood sugar levels were not checked. During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medication to meet the need for one of eight sampled residents (Resident 20) when Resident 20's Lactulose (brand name-laxative medication taken to treat constipation) was not available for administration for one day (5/15/24). This failure had the potential for Resident 20 to develop constipation which could lead to more serious health condition like stool impaction (the result of severe constipation, unable to regularly pass stool or feces and it backs up inside the large intestine (colon). Findings: During a concurrent medication pass observation and interview on 5/15/24 at 8:22 a.m. at A- hallway, Licensed Vocational Nurse (LVN) 3, was preparing Resident 20's medications. LVN 3 did not administer Resident 20's lactulose medication. LVN 3 stated the medication was not available to give to Resident 20. During a review of Resident 20's admission Record (AR-document with resident demographic and medical diagnosis information), dated 5/16/24,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate food texture was provided for one of six sampled residents (Resident 11) when Resident 11 did not received large portions finger foods as ordered. This failure placed Resident 11 at risk for weight loss due to not being able to utilize utensils. Findings: During a concurrent observation, interview and record review on 5/13/24 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1 in the dining room, Resident 11 was observed eating lunch. In Resident 11's plate, there were two whole pieces of chicken breast, steamed rice, cut up broccoli and fruit cobbler in a dessert bowl. Review of meal tray ticket indicated, .Large Portions FINGER FOODS . CNA 1 stated she served the tray to Resident 11 and did not know Resident 11's diet was regular finger foods. CNA 1 stated she did not check the food in the tray when she served the food to Resident 11 because the licensed nurse already checked the tray and did not find any…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for one of five sampled residents (Resident 34) when brown-colored, fecal stains and remnants (remaining, small amount) was found on the toilet and toilet seat in Resident 34's bathroom. This failure had the potential of cross-contamination from one resident to another. Findings: During an interview on 5/13/24 at 7:52 a.m. with Resident 34 in his room, Resident 34 stated his bathroom was dirty with feces and urine. Resident 34 stated, when other residents use the bathrooms; there were remnants of feces and urine. Resident 34 stated, he did not feel comfortable in using the bathroom due to the issues with cleanliness. During an observation on 5/13/24 at 8:07 a.m. in Resident 34's room, fecal matter was observed smeared on the toilet seat and toilet bowl in Resident 34's bathroom. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) Section C, dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to implement care plan intervention for one of seven sampled residents (Resident 1), when the facility did not provide continuous monitoring as indicated in Residnt1 ' s care plan and Resident 1 eloped (left the health care facility unsupervised and undetected) from the facility on 9/23/23. This failure resulted in Resident 1 leaving the facility unsupervised and had a potential for accident which could lead to serious injury. Findings: During a review of Resident 1 ' s admission Record (AR-a document with personal identifiable and medical information), dated 11/2/23, the AR indicated, Resident 1 was admitted in the facility on 4/25/23, with diagnosis which included dementia (loss of cognitive functioning- thinking, remembering, and reasoning — to such an extent that it interferes with a person's daily life and activities ), depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities), anxiety (a feeling of fear, dread, and uneasiness) and muscle weakness. During an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-01 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents were provided care and services according to acceptable standards of clinical practice for one of seven sampled residents (Resident 6), when Resident 6 was admitted with Pressure ulcers (an injury that break down the skin and underlying tissue) on 9/21/2023. The admission skin assessment indicated the skin was intact and the treatments for pressure ulcers did not start till 9/27/2023. This failure resulted in a delay of treatment and care for Resident 6 ' s pressure ulcers which had the potential for worsening, developing infections and death. Findings: During a review of Resident 6 ' s Face Sheet (FS- a document that gives a Patient ' s information at a quick glance) dated 9/21/23, the FS indicated, .Pressure ulcer sacral region (area by the tailbone), stage 3 (a stage of pressure ulcer development where the top two layers of skin down to the fatty areas are opened and exposed) . Pressure ulcer left ankle, unstageable (cannot be staged), Pressure-Induced Deep Tissue Damage (a form of pressure ulcer or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-01 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure appropriate treatment and services were provided for two of seven sampled residents (Resident 2 and 5 ) when: 1. Resident 5 ' s tube feeding container and water bag (a bag filled with water attach to the feeding tube to clear the tube) was not labeled with name of the resident, the type of formula and the rate per physician ' s order. This failure placed Resident 5 at risk for receiving the wrong formula resulting in malnutrition and dehydration. 2. Resident 2 ' s G-tube (gastrostomy tube-a tube that is connected to the stomach or intestines used provide nutrition to a person) was observed to have brown, beige matter build up around the connection port. This failure placed resident 2 at risk for infection where bacteria (microscopic organisms) from the matter build up on the connector sites of the G-Tube travel down to the insertion site and into the stomach. Findings: 1. During a concurrent observation and interview on [DATE]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-11 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Intakes: CA00855412, CA00856005, CA00856175 Based on interview and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation (the act of using someone unfairly for your own advantage) that prohibit and prevent abuse for two of two sampled residents (Resident 1 and Resident 2), when the facility did not provide a safe environment and protection that would prevent Resident 1 from entering Resident 2 ' s room to perform a sexual act and protect Resident 2 from Resident 1 entering his room to perform a sexual act. This failure resulted in nonconsensual (sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur) sexual abuse to Resident 1 and Resident 2. Findings: During a review of Resident 1's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of resident) was developed and implemented to meet the identified needs for one of two sampled residents (Resident 1), when Resident 1 did not have a resident-centered care plan developed after Resident 1 performed a nonconsensual (sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur) sexual act to Resident 2. This failure had the potential to result in Resident 1 ' s identified care needs, to go unmet and placed Resident 1 at risk of not receiving appropriate, consistent, and individualized care interventions to ensure the safety of Resident 1. Findings: During a review of Resident 1's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a safe, comfortable and a homelike environment for one of five residents (Resident 1) when privacy curtains were torn, frayed (unraveled or worn at the edge), and not hung correctly in Resident 1 ' s room. This failure resulted in Resident 1 not being provided a comfortable, functional, homelike environment and had the potential to negatively affect the mental and emotional well-being of Resident 1. Findings: During an observation on 07/06/23 at 11:53 a.m., in Resident 1 ' s room, the privacy curtains rod (a device used to suspend curtains) of her room was broken and the curtains were not functioning correctly. The curtains did not provide full privacy. During a concurrent observation and interview on 07/06/23 at 12:03 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 1 ' s room, the privacy curtains were observed. CNA 1 stated the privacy curtains in Resident 1 ' s room were not in good working condition and should have been replaced. During an interview on 07/06/23 at 12:06 p.m. with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-05-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety when: 1. In the small refrigerator in the kitchen, there was unlabeled prepared milk and sugar free juice cups and a pitcher of sugar free orange juice. 2. In the large refrigerator, there was a carton of unlabeled liquid eggs and a bag of shredded lettuce. 3. On the dry food rack there was an unlabeled container of popcorn kernels. 4. In the freezer there was unlabeled frozen waffles and mixed veggies in a bag. These failures resulted in unsafe food handling practices which placed the residents at risk of contracting foodborne illness. Findings: 1. During a concurrent kitchen observation and interview with [NAME] 1, on 5/19/19, at 8:14 a.m., she stated there was a small refrigerator and large refrigerator and one freezer in the kitchen area. In the small refrigerator, there were 10 prepared milk and eight juice cups without a label. There was a pitcher with orange liquid without a label. [NAME] 1 stated the liquid was sugar free juice.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-23 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (an advocate for residents) was notified of the emergency transfer for three of three residents (Residents 18, 30, and 51), when Residents 18, 30, and 51 were transferred to a general acute care hospital (GACH). This failure had the potential of not providing Residents 18, 30, and 51 with access to an advocate who could inform them of their options and rights. Findings: During an interview with the Social Services Director (SSD), on 5/22/19, at 11:58 a.m., the SSD stated he was responsible to notify the ombudsman for residents in the facility who had unplanned discharges or emergency transfers to the hospital. During a concurrent interview with the SSD and record review for Residents 18, 30, and 51, on 5/22/19, at 12:27 p.m., the SSD stated Residents 18, 30, and 51 had unplanned discharges and were transferred to the hospital. The SSD reviewed the clinical records for Residents 18, 30, and 51 and was unable to find documentation regarding if the ombudsman was notified of the transfer.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-23 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan (a plan that provides direction for individualized care of the resident) for three of 21 sampled residents (Residents 7, 18, and 30) when: 1. For Resident 7, the facility failed to implement the care plan for a psychotropic (affecting mental activity, behaviors, and perceptions) medication when Resident 7's olanzapine (an anti-psychotic medication used to treat mental/mood conditions) had no resident specific targeted behaviors identified for monitoring. This failure had the potential to result in Resident 7 not to receiving the appropriate plan of care for the use of psychotropic medication. 2. For Residents 18 and 30, the facility failed to develop a care plan related to the use of side rails. This failure placed Residents 18 and 30 at risk of not receiving appropriate, consistent, and individualized care interventions to ensure their safety and well-being. Findings: 1. During an concurrent interview with Licensed Vocational Nurse (LVN) 1 and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-23 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise care plans for two of 21 sampled residents (Resident 7 and Resident 9) when: 1. For Resident 7, the facility did not revise the care plan to reflect the specific behavior monitoring for the use of an anti-depressant medication, fluoxetine. 2. For Resident 9, the facility did not revise the care plan to reflect the specific behavior monitoring for the use of an anti-psychotic medication, quetiapine. These failures had the potential for Resident 7 and Resident 9's behavior manifestations to be unrecognized by staff for accurate evaluations of the effect of the medication treatments. Findings: 1. During a concurrent interview with Licensed Vocational Nurse (LVN) 1, and record review for Resident 7, on 5/22/19, at 2:25 p.m., she stated Resident 7 was ordered fluoxetine (a medication used to depressive disorder) 60 mg (milligram, unit of measurement) by mouth every day for depressive disorder manifested by self isolation. LVN 1 reviewed Resident 7's care plans and stated there was a care plan for Resident 7's diagnosis…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-23 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide nursing services in accordance with professional standards of practice and facility policy and procedure for two of eight sampled residents (Residents 43 and 46), when the Registered Nurse (RN) left an unlabeled medication cup with medications at the bedside unattended. For Residents 43 and 46, this failure had the potential for an unintended resident to take another residents' medications. Findings: 1. During a medication administration observation with the RN, on 5/21/19, at 4:07 p.m., the RN prepared seven medications for Resident 43 to take orally, which included: clonidine (medication used to treat high blood pressure) tablet 0.1 milligrams ([mg] unit of measurement); divalproex sodium (medication used to treat psychotic behavior) tablet delayed release 250 mg; gabapentin (a neurotransmitter, often used to treat pain) capsule 300 mg; glipizide (medication used to help control high blood sugar levels) tablet 5 mg; hydralazine…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-23 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform assessments that identified the risks and benefits of the use of side rails for three of 7 sampled residents (Resident 18, 30, and 41) and failed to obtain informed consent for Resident 18 when: 1. For Residents 18 and 30, the facility failed to assess for entrapment, attempt alternatives, and offer least restrictive measures prior to the use of side rails. 2. For Resident 41, the facility failed to obtain consent, a physician order, assess for entrapment, attempt alternatives, and offer least restrictive measures prior to the use of side rails. These failures had the potential to put Residents 18, 30, and 41 at risk for entrapment and serious injury. Findings: 1. During an observation on 5/19/19, at 8:15 a.m., in the resident's room, Resident 18 was lying in bed, eyes closed, with a left half upper side rail elevated. During an observation on 5/19/19, at 10:35 a.m., in the resident's room, Resident 18 was lying in bed, eyes…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-23 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete and transmit a significant change Minimum Data Set (MDS) assessment (required assessment of cognitive and functional abilities) in resident status for one of 21 sampled residents (Resident 18) when Resident 18 was admitted for hospice (end of life care) services. For Resident 18, this failure had the potential for Resident 18 to not have care needs met as related to a change in condition. Findings: During a concurrent interview with the MDS Coordinator (MDSC) and record review for Resident 18, on 5/22/19, at 12:21 p.m., the MDSC stated Resident 18 was admitted to hospice services on 3/19/19 with an admitting diagnosis of pancreatic mass. The MDSC reviewed the MDS assessments for Resident 18 and stated she had not completed a significant change MDS in resident status after Resident 18 was admitted to hospice services. The MDSC stated there should have been a significant change MDS assessment done when there was a status change and when Resident 18 was admitted to hospice services. The MDSC stated a significant…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-23 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 21 sampled residents' (Residents 18 and 30) use of side rails were accurately coded when the side rails were coded as restraints on the Minimum Data Set ([MDS] resident assessment tool which indicates physical and cognitive abilities) assessments. This had the potential for the residents' side rails to be used by staff as restraints and restricting Resident 18 and Resident 30's mobility. Findings: 1. During an observation on 5/19/19, at 8:15 a.m., in the resident's room, Resident 18 was lying in bed, eyes closed, with a left half upper side rail elevated. During an interview with Certified Nursing Assistant (CNA) 1, on 5/22/19, at 8:42 a.m., she stated Resident 18 required nursing staff's assistance with her activities of daily living (self care activities such as eating, toileting, bathing, dressing, and moving in bed) and grabbed the side rail to assist her with mobility. During a concurrent interview with Licensed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-05-17 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview during the survey period of 5/13/24 to 5/17/24, the facility failed to provide and maintain minimum square footage for each resident in 12 of 19 rooms (Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19). Findings: During an observation of the facility on 5/13/24 to 5/17/24, the following rooms did not provide the minimum square footage as required by the regulation: Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19. The residents had reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Room # Square Feet # Residents 7 203.7 3 8 210.2 3 9 213.3 3 10 209.1 3 11 203.2 3 12 209.5 3 13 154.0 2 14 152.4 2 15 159.2 2 16 158.2 2 17 154.9 2 19 154.7 2 Recommend waiver continue in effect. _______________________________ Health Facility Evaluator Nurse / Date Request continuance of waiver.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Waiver has been granted
  • No harm found · Bcited before2019-05-23 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation during the survey period of 5/19/19 to 5/23/19, the facility failed to provide and maintain minimum square footage for each resident in 12 of 19 rooms (Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19). Findings: During an observation of the facility on 5/19/19 to 5/23/19, the following rooms did not provide the minimum square footage as required by the regulation: Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19. The residents had a reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Room # Square Feet # Residents 7 203.7 3 8 210.2 3 9 213.3 3 10 209.1 3 11 203.2 3 12 209.5 3 13 154.0 2 14 152.4 2 15 159.2 2 16 158.2 2 17 154.9 2 19 154.7 2 Recommend waiver continue in effect. ______________________________ Health Facility Evaluator Nurse / Date Request continuance of waiver. ________________________…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AJC HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 3 of 53.7-0.7 vs chain
The other 13 homes this chain runs (chain average 2.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
EVERGREEN CARE CENTER HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 05/17/2019
SWC CA OPCO, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2021
CHESLEY, AARONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 02/01/2021
SMITH, PHYLICIAIndividualW-2 MANAGING EMPLOYEEsince 02/01/2021
GAMETT, JAMESIndividualCORPORATE OFFICERsince 02/01/2021

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.6M
Net patient revenuemost recent cost report
+33.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 74%Medicare 9%Other / private 17%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$355per resident / day
operating cost
$10,786per month
≈ monthly operating cost
$530per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555920. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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